Extracorporeal Treatment for Metformin Poisoning

Today’s pearl highlights an excellent resource for managing poisoned patients.

Is metformin dialyzable?

The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup was established to provide evidence-based recommendations for different toxins. Their website has many helpful resources, including all of their peer-reviewed publications. I will share recommendations for other individual poisons in future pearls.

For today, we’ll focus on metformin:

General Recommendation:

  • Extracorporeal treatment (ECTR) is recommended in severe metformin poisoning


ECTR is indicated if ANY of the following conditions are present:

  • Lactate concentration greater than 20 mmol/L
  • pH ≤ 7.0
  • Shock
  • Failure of standard supportive measures
  • Decreased level of consciousness

Cessation of ECTR is indicated when:

  • ECTR should be continued until the lactate concentration is less than 3 mmol/L


  • pH > 7.35, at which time close monitoring is warranted to determine the need for additional ECTR courses

Choice of ECTR:

  • Intermittent hemodialysis is preferred initially
  • Continuous renal replacement therapies may be considered if hemodialysis is unavailable
  • Repeat ECTR sessions may use hemodialysis or continuous renal replacement therapy


Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

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